347000389-5-4-2023-59-AS-KHOS-CRLVHM-20230507162722

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347000389
Report Date: 05/04/2023
Date Signed: 05/04/2023 11:26:43 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/09/2023 and conducted by Evaluator Cassie Yang

COMPLAINT CONTROL NUMBER: 59-AS-20230309130818

FACILITY NAME:	ATRIA EL CAMINO GARDENS		FACILITY NUMBER:	347000389
ADMINISTRATOR:	KIMBERLY HAGEN		FACILITY TYPE:	740
ADDRESS:	2426 GARFIELD AVE		TELEPHONE:	(916) 488-5722
CITY:	CARMICHAEL	STATE: CA	ZIP CODE:	95608
CAPACITY:	325	CENSUS: 188	DATE:	05/04/2023
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Kim Hagen		TIME COMPLETED:	11:45 AM

ALLEGATION(S):

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Facility tampered with resident's records.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Cassie Yang arrived unannounced to deliver the finding for the allegation listed above. LPA met with Executive Director, Kim Hagen, and explained the purpose of the visit. LPA ensured hand sanitizer was applied before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask.

During the investigation of this complaint, the Department conducted interviews and record review for the allegations cited above.

Please continue report on LIC 9099-C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie Yang	TELEPHONE: 916-201-1928
LICENSING EVALUATOR SIGNATURE:	DATE: 05/02/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 59-AS-20230309130818

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: ATRIA EL CAMINO GARDENS	FACILITY NUMBER: 347000389
	VISIT DATE: 05/04/2023

NARRATIVE

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Continued from LIC 9099...

Allegation: Facility tampered with resident's records.
The Department conducted record review and interviews to investigate this allegation. Interview conducted with R1 indicated that R1 believed facility intentionally altered R1's LIC 602 in order to increase R1's rent. During interview conducted on 03/17/2023 with ED indicate a new LIC 602 was faxed in by R1's primary care physician (PCP) after ED and SW addressed concerns to R1's PCP regarding R1's medication. Record review indicate that R1 signed an Authorization To Release Health Information form which permits facility to contact R1's PCP for medical purposes. Record review indicate that R1 has five (5) LIC 602 since October 2022. LPA observed first LIC 602 to be dated 10/9/2022, second LIC 602 dated 11/29/2022, third LIC 602 dated 12/7/2022, fourth LIC 602 dated 12/9/2022, and the fifth LIC 602 dated 01/10/2023.

Based on interviews conducted, the preponderance of evidence standards have not been met. Therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview conducted and a copy of the report and appeal rights was provided.

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie Yang	TELEPHONE: 916-201-1928
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023

LIC9099 (FAS) - (06/04)

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